Lung protective strategies grooms

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  • They even incorporated Recruitment maneuvers into
  • Ventilating Rats
  • Lung protective strategies grooms

    1. 1. Lung Protective Strategies: The Effects of Vt, PEEP & Alveolar Recruitment David Grooms BS, RRT Sentara Norfolk General, Leigh & Bayside Hospitals
    2. 2. Understanding ARDS……. 2 Types <ul><li>Extrapulmonary ARDS (In-direct) </li></ul><ul><li>Pulmonary ARDS (Direct) </li></ul>
    3. 3. Identifying ARDS…….2 Types? <ul><li>Pulmonary ARDS (Direct) </li></ul><ul><li>Pneumonia: Bacterial or Viral </li></ul><ul><li>Inhalation of noxious agent </li></ul><ul><li>Aspiration of Gastric Contents </li></ul><ul><li>Isolated pulmonary contusion </li></ul><ul><li>Fat Embolus syndrome </li></ul><ul><li>Extrapulmonary ARDS (In-direct) </li></ul><ul><li>Multi-system Trauma </li></ul><ul><li>Transfusion related ALI </li></ul><ul><li>Acute pancreatitis </li></ul><ul><li>Sepsis </li></ul><ul><li>Post- CABG surgery </li></ul><ul><li>Hemorrahagic shock </li></ul>Kallet, R & Branson, R. Resp. Care Journal, Apr 2007, Vol 52 No 4
    4. 4. Characteristics of Extrapulmonary ARDS (In-direct) Viera et al. Am J Respir Crit Care Med 1998:158
    5. 5. Contrasts between 2 types of ARDS Kallet, R & Branson, R. Resp. Care Journal, Apr 2007, Vol 52 No 4 >10 usually present Lower inflec. Pt Severely Reduced Reduced Lung Compl. Response to PEEP Recruitment Potential Risk of overdistention Normal Reduced Chest Wall Compliance Pulmonary ARDS Extrapulmonary ARDS Mechanics
    6. 6. Characteristics of Extrapulmonary ARDS (In-direct) Viera et al. Am J Respir Crit Care Med 1998:158
    7. 7. Contrasts between 2 types of ARDS Kallet, R & Branson, R. Resp. Care Journal, Apr 2007, Vol 52 No 4 >10 usually present Lower inflec. Pt Severely Reduced Reduced Lung Compl. Response to PEEP Recruitment Potential Low Risk of overdistention Normal Reduced Chest Wall Compliance Pulmonary ARDS Extrapulmonary ARDS Mechanics
    8. 8. Characteristics of Extrapulmonary ARDS (In-direct) Viera et al. Am J Respir Crit Care Med 1998:158
    9. 9. Contrasts between 2 types of ARDS Kallet, R & Branson, R. Resp. Care Journal, Apr 2007, Vol 52 No 4 >10 usually present Lower inflec. Pt Severely Reduced Reduced Lung Compl. Excellent (10-20 cm) Response to PEEP High Recruitment Potential Low Risk of overdistention Normal Reduced Chest Wall Compliance Pulmonary ARDS Extrapulmonary ARDS Mechanics
    10. 10. Characteristics of Extrapulmonary ARDS (In-direct) Viera et al. Am J Respir Crit Care Med 1998:158
    11. 11. Contrasts between 2 types of ARDS Kallet, R & Branson, R. Resp. Care Journal, Apr 2007, Vol 52 No 4 <10 cm often absent >10 usually present Lower inflec. Pt Severely Reduced Reduced Lung Compl. Excellent (10-20cm) Response to PEEP High Recruitment Potential Low Risk of overdistention Normal Reduced Chest Wall Compliance Pulmonary ARDS Extrapulmonary ARDS Mechanics
    12. 12. Characteristics of Pulmonary ARDS (Direct) Viera et al. Am J Respir Crit Care Med 1998:158
    13. 13. Contrasts between 2 types of ARDS Kallet, R & Branson, R. Resp. Care Journal, Apr 2007, Vol 52 No 4 <10 cm often absent >10 usually present Lower inflec. Pt Severely Reduced Reduced Lung Compl. Excellent (10-20cm) Response to PEEP High Recruitment Potential High Low Risk of overdistention Normal Reduced Chest Wall Compliance Pulmonary ARDS Extrapulmonary ARDS Mechanics
    14. 14. Characteristics of Pulmonary ARDS (Direct) Viera et al. Am J Respir Crit Care Med 1998:158
    15. 15. ARDS CT and PV Curve (slow inflation) # 6 -10 0 10
    16. 16. ARDS CT and PV Curve (slow inflation) # 7
    17. 17. ARDS CT and PV Curve (slow inflation) # 8
    18. 18. ARDS CT and PV Curve (slow inflation) # 9
    19. 19. ARDS CT and PV Curve (slow inflation) # 10
    20. 20. ARDS CT and PV Curve (slow inflation) # 11
    21. 21. ARDS CT and PV Curve (slow inflation ) # 12
    22. 22. ARDS CT and PV Curve (slow inflation) # 13
    23. 23. ARDS CT and PV Curve (slow inflation) # 14
    24. 24. ARDS CT and PV Curve (slow inflation) # 15
    25. 25. ARDS CT and PV Curve (slow inflation) # 16
    26. 26. ARDS CT and PV Curve (slow inflation) # 17
    27. 27. ARDS CT and PV Curve (slow inflation) # 18
    28. 28. ARDS CT and PV Curve (slow inflation) # 19
    29. 29. ARDS CT and PV Curve (slow inflation) # 20
    30. 30. ARDS CT and PV Curve (slow inflation) # 21
    31. 31. ARDS CT and PV Curve (slow inflation) # 22
    32. 32. ARDS CT and PV Curve (slow inflation) # 23
    33. 33. ARDS CT and PV Curve (slow inflation) # 24
    34. 34. ARDS CT and PV Curve (slow inflation) # 25
    35. 35. ARDS CT and PV Curve (slow inflation) # 26
    36. 36. ARDS CT and PV Curve (slow inflation) # 27
    37. 37. ARDS CT and PV Curve (slow inflation) # 28
    38. 38. ARDS CT and PV Curve (slow inflation) # 29
    39. 39. ARDS CT and PV Curve (slow inflation) # 30
    40. 40. ARDS CT and PV Curve (slow inflation) # 31
    41. 41. ARDS CT and PV Curve (slow inflation) # 32
    42. 42. ARDS CT and PV Curve (slow inflation) # 33
    43. 43. ARDS CT and PV Curve (slow inflation) # 34
    44. 44. ARDS CT and PV Curve (slow inflation) # 35
    45. 45. ARDS CT and PV Curve (slow inflation) # 36
    46. 46. ARDS CT and PV Curve (slow inflation) # 37
    47. 47. ARDS CT and PV Curve (slow inflation) # 38
    48. 48. ARDS CT and PV Curve (slow inflation) # 39
    49. 49. ARDS CT and PV Curve (slow inflation) # 40
    50. 50. ARDS CT and PV Curve (slow inflation) # 41
    51. 51. ARDS CT and PV Curve (slow inflation) # 42
    52. 52. ARDS CT and PV Curve (slow inflation) # 43
    53. 53. ARDS CT and PV Curve (slow inflation) # 44
    54. 54. ARDS CT and PV Curve (slow inflation) # 45
    55. 55. ARDS CT and PV Curve (slow inflation) # 46
    56. 56. ARDS CT and PV Curve (slow inflation) # 47
    57. 57. ARDS CT and PV Curve (slow inflation) # 48
    58. 58. ARDS CT and PV Curve (slow inflation) # 49
    59. 59. ARDS CT and PV Curve (slow inflation) # 50
    60. 60. ARDS CT and PV Curve (slow inflation) # 51
    61. 61. ARDS CT and PV Curve (slow inflation) # 52
    62. 62. ARDS CT and PV Curve (slow inflation) # 53
    63. 63. ARDS CT and PV Curve (slow inflation) # 54
    64. 64. ARDS CT and PV Curve (slow inflation) # 55
    65. 65. ARDS CT and PV Curve (slow inflation) # 56
    66. 66. ARDS CT and PV Curve (slow inflation) # 57
    67. 67. ARDS CT and PV Curve (slow inflation) # 58
    68. 68. ARDS CT and PV Curve (slow inflation) # 59
    69. 69. ARDS CT and PV Curve (slow inflation) # 60
    70. 70. Contrasts between 2 types of ARDS Kallet, R & Branson, R. Resp. Care Journal, Apr 2007, Vol 52 No 4 <10 cm often absent >10 usually present Lower inflec. Pt Severely Reduced Reduced Lung Compl. Excellent (10-20cm) Response to PEEP Low High Recruitment Potential High Low Risk of overdistention Normal Reduced Chest Wall Compliance Pulmonary ARDS Extrapulmonary ARDS Mechanics
    71. 71. Characteristics of Pulmonary ARDS (Direct) Viera et al. Am J Respir Crit Care Med 1998:158
    72. 72. Contrasts between 2 types of ARDS Kallet, R & Branson, R. Resp. Care Journal, Apr 2007, Vol 52 No 4 <10 cm often absent >10 usually present Lower inflec. Pt Severely Reduced Reduced Lung Compl. Good (8-12cm) Excellent (10-20cm) Response to PEEP Low High Recruitment Potential High Low Risk of overdistention Normal Reduced Chest Wall Compliance Pulmonary ARDS Extrapulmonary ARDS Mechanics
    73. 73. Characteristics of Pulmonary ARDS (Direct) Viera et al. Am J Respir Crit Care Med 1998:158
    74. 74. Effects of Mechanical/Physical Stretch on Rat Alveolar Epithelial Cells <ul><li>Tschumperlin, D et al. Am J Respir Crit Care Med, Vol 162. pp 357-362, 2000 </li></ul><ul><li>Excised Rat lungs </li></ul><ul><li>Placed Alveolar Epithelial Cells in a “cell-stretching device” </li></ul>
    75. 75. Tschumperlin, D et al. Am J Respir Crit Care Med, Vol 162. pp 357-362, 2000
    76. 76. Tschumperlin, D et al. Am J Respir Crit Care Med, Vol 162. pp 357-362, 2000 Both static and single deformations were significantly less injurious than cyclic deformations at each deformation level
    77. 77. Tschumperlin, D et al. Am J Respir Crit Care Med, Vol 162. pp 357-362, 2000 Reducing the amplitude reduced cell death Cell Death dependent on frequency
    78. 78. ARDS Network
    79. 79. ARDS Network <ul><li>Multicenter, Randomized trial </li></ul><ul><li>861 Patients recruited from March 1996 through March 1999 at 10 university centers. </li></ul><ul><li>Patients enrolled if: </li></ul><ul><li>1) They were receiving mechanical ventilation </li></ul><ul><li>2) Had acute decrease in the P/F ratio (<300) </li></ul><ul><li>3) Bilateral pulmonary infiltrates on a chest radiograph consistent with the presence of edema </li></ul><ul><li>4) No clinical evidence of left atrial hypertension or if measure a PCWP<18mmHg . </li></ul>
    80. 81. Results <ul><li>Trial was stopped after fourth interim analysis. </li></ul><ul><li>Mortality rates </li></ul><ul><ul><li>12 cc/Kg VT group- 39.8% </li></ul></ul><ul><ul><li>6cc/Kg Vt group- 31.0% </li></ul></ul><ul><ul><li>Mortality decreased by 22% </li></ul></ul><ul><li>Vt & Plat were significantly lower </li></ul><ul><li>Question to you- </li></ul><ul><li>What group had better PaO2’s? </li></ul><ul><li>12 & they died more often- so better PaO2 does not translate into better outcomes </li></ul>
    81. 82. What did we do then? <ul><li>We were skeptical at the results. Didn’t like it because Vt was so low. </li></ul><ul><li>Also questioned that mortality could have been better if more PEEP was used or use of Recruitment Maneuvers. </li></ul><ul><li>Did we interpret the results of the studies right??? </li></ul>
    82. 83. Lower PEEP/Higher FiO 2 FiO 2 .3 .4 .4 .5 .5 .6 .7 .7 .7 .8 .9 .9 .9 1.0 PEEP 5 5 8 8 10 10 10 12 14 14 14 16 18 18-24 Higher PEEP/Lower FiO 2 FiO 2 .3 .3 .4 .4 .5 .5 .5-.8 .8 .9 1.0 PEEP 12 14 14 16 16 18 20 22 22 22-24 Target enrollment- 750 ALI, ARDS pts.
    83. 84. Recruitment Maneuver Attempts <ul><li>RM’s were performed on the first 80 patients assigned to the higher PEEP group. </li></ul><ul><li>1 or 2 manuevers per day @ 35-40cmH2O for 30 seconds. </li></ul><ul><li>Mean increase in O2sat was “small & transient.” Therefore RM were DC’d for the remainder of the trial. </li></ul>
    84. 85. Results <ul><li>Trial stopped @ the 2 nd interim analysis after 549 pts. Had been enrolled. </li></ul><ul><li>Stopped based on the specified futility stopping rule. </li></ul><ul><li>Surprising Results </li></ul>ESSENTIALLY NO DIFFERENCE IN OUTCOMES (MORTALITY)
    85. 86. Interpretation….. <ul><li>PEEP does not improve mortality of ARDS patients. </li></ul><ul><li>Added to our own confusion </li></ul><ul><li>Now what do we do if PEEP doesn’t help survival </li></ul><ul><li>Instead of developing my own interpretation of the results, I will wait around until someone shows me the right way to do it. </li></ul><ul><li>Do our dirty work for us!!! </li></ul>
    86. 87. So what can we do to try to do it right?? <ul><li>Question aspects of personal satisfaction vs. patient overall satisfaction </li></ul>VS I got the PaO2 up from 70-80 by turning the Vt up to 1200cc. You know I am the man right? Wow, awesome job, I will try to get it higher than you did today! You are the man
    87. 88. So what can we do to try to do it right?? <ul><li>Example: Patient with ALI/ARDS </li></ul><ul><li>Steps to take to minimize progression of syndrome </li></ul><ul><li>Minimize FIO2, make all attempts to decrease FIO2 < 60%. </li></ul>
    88. 89. Oxygen Dissociation Curve ARDSnet Study 88-94% PaO2 55-80
    89. 90. So what can we do to try to do it right?? <ul><li>Example: Patient with ALI/ARDS </li></ul><ul><li>Steps to minimize progression of disease/syndrome </li></ul><ul><li>Minimize FIO2, make all attempts to decrease FIO2 < 60%. </li></ul><ul><li>Management and consideration of Vt </li></ul>
    90. 91. Can mechanical ventilation actually produce lung injury? <ul><li>Webb & Tierney, 1974, Am Rev Respir Dis 110:556-565 </li></ul>
    91. 92. Key Findings of the study <ul><li>Healthy Lungs with low PIP does not cause lung injury </li></ul><ul><li>Ventilation with high PIP (30-45) & no PEEP produces perivascular edema & leads to severe injury. </li></ul><ul><li>PEEP provides protection from alveolar edema due to high PIP. </li></ul><ul><li>Webb & Tierney, 1974, Am Rev Respir Dis </li></ul><ul><li>110:556-565 </li></ul>
    92. 93. Overdistention/Increased Transalveolar Pressure of Good alveoli Nieman, G
    93. 94. Take Home <ul><li>Minimize Stretching of Healthy Alveoli by reducing Vt or Plat pressure. </li></ul><ul><li>OK but what about patients that do not have ALI/ARDS?? </li></ul>
    94. 95. Crit Care Med 2004 Vol. 32, No. 9
    95. 96. Results <ul><li>VT’s above 9cc/Kg cause VILI in non- ARDS patients. </li></ul><ul><li>The incidence of </li></ul><ul><li>VILI is higher in pts. </li></ul><ul><li>who get >9cc/Kg </li></ul><ul><li>VT. & blood transfusions. </li></ul>What if I go too low on the Vt because I am trying to protect?
    96. 97. Pt. Switched To AVTS Mode. Maintained @ 8-9cc’s/Kg Pt. Placed on 6cc/Kg Vt Pt. Placed on 8-9cc/Kg Vt Pt. Placed on 6cc/Kg Vt SNGH Burn/Trauma Unit
    97. 98. So what can we do to try to do it right?? <ul><li>Example: Patient with ALI/ARDS </li></ul><ul><li>Steps to take to minimize progression of syndrome </li></ul><ul><li>Minimize FIO2, make all attempts to decrease FIO2 < 60%. </li></ul><ul><li>Management and consideration of Vt </li></ul><ul><li>Management of PEEP </li></ul>
    98. 99. How to set PEEP <ul><li>Use PEEP FIO2 table from ARDSnet study </li></ul><ul><li>FiO2 .3 .4 .4 .5 .5 .6 .7 .7 .7 .8 .9 .9 .9 1.0 </li></ul><ul><li>PEEP 5 5 8 8 10 10 10 12 14 14 14 16 18 18-24 </li></ul><ul><li>This table is designed to be appropriate for the average patient, but sometimes PEEP needs to be individualized </li></ul>
    99. 100. How to set PEEP <ul><li>Use PEEP FIO2 table from ARDSnet study </li></ul><ul><li>Set PEEP based off Lower Inflection point (pflex) </li></ul>
    100. 101. Rimensberger P et al. CCM 1999;27:1940-1945
    101. 102. Crit Care Med 2006 Vol. 34, No. 5
    102. 103. Villar, et al. Crit Care Med 2006 Vol. 34, No. 5 Amato, M. et al. 1998. NEJM
    103. 104. Minimizing Atelectatictrauma (repeated opening and closing) Nieman, G.
    104. 105. How to manage PEEP <ul><li>Use PEEP FIO2 table from ARDSnet study </li></ul><ul><li>Set PEEP based off Lower Inflection point (pflex) +1-2cm </li></ul><ul><li>Set PEEP based off Point of maximum Curvature or recruitable lung volume via deflation limb of PV curve </li></ul>
    105. 106. The Effects of Recruitment on End-expiratory Lung Volume Barbas CSV Am J Respir Crit Care Med 2002;165:A218 APRV/HFOV puts pt. at this point
    106. 107. <ul><ul><ul><li>Hickling K. AJRCCM 2001;163:69-78. </li></ul></ul></ul>APRV/HFOV puts pt. at this point
    107. 108. Rimensberger P et al. CCM 1999;27:1940-1945
    108. 109. +350 cc’s
    109. 111. Maximizing a current modality <ul><li>Not how much but HOW! </li></ul><ul><li>Pressure Modes: Use of Flow Time pattern for adequate inspiratory phase to improve gas distribution and minimize level of pressure needed for ventilation </li></ul>
    110. 112. I-times in Pressure Modes for Full Flow deceleration improve gas distribution and minimize PC level F T P T MAP MAP Vt Vt
    111. 113. I-times in Pressure Modes for Full Flow deceleration improve gas distribution and minimize PC level F T P T MAP Vt Vt
    112. 114. I-times in Pressure Modes for Full Flow deceleration improve gas distribution and minimize PC level F T P T MAP Vt Min.Insp. Pressure Adjustments Needed Vt Vt
    113. 115. Maximizing a current or alternative modality <ul><li>Not how much but HOW! </li></ul><ul><li>Pressure Modes: Use of Flow Time pattern for adequate inspiratory phase to improve gas distribution and minimize level of pressure needed for ventilation </li></ul><ul><li>Use of Airway Pressure Release Ventilation (APRV), HFOV, Jet Ventilation </li></ul>
    114. 116. Normal Ventilation with Normal MAP P Time PEEP PEEP Plat Peak Insp Mean Insp Pressure Mean Exp Pressure + = MAP 5 20 15
    115. 117. Increase in Insp. Pressure What will happen to MAP? P Time PEEP PEEP Plat Peak Insp Mean Insp Pressure Mean Exp Pressure + = MAP 5 20 15 25
    116. 118. Increase in Insp. Pressure What will happen to Plat ? P Time PEEP PEEP Plat Peak Insp Mean Insp Pressure Mean Exp Pressure + = MAP 5 20 15 25
    117. 119. Increase in PEEP, What will happen to MAP & Plat? P Time PEEP PEEP Plat Peak Insp Mean Insp Pressure Mean Exp Pressure + = MAP 5 20 15 10
    118. 120. APRV (Basically inverse Ratio with Spont. Breathing during insp. Phase.) Can Increase MAP and keep safe Plat. & spont. Breath. P Time PEEP PEEP Plat Peak Insp Mean Insp Pressure Mean Exp Pressure + = MAP 5 20 15 = If Flow is Fully dec. Spontaneous Breaths
    119. 122. Summary <ul><li>Understand disease type, what is cause for inflammation of the Lung </li></ul><ul><li>Manage FIO2 < 60% with PaO2 > 60mmHg & SpO2 > 88% </li></ul><ul><li>Manage Vt (4-8cc/KgIBW) & Plateau Pressure < 30cmH2O to minimize stretch on good and bad alveoli. >9cc/Kg IBW in non ARDS patients increases incidence of ALI developement </li></ul><ul><li>Commericial Vents actually incorporate an automatic Lung Protective Strategy (Hamilton Galileo/ASV Mode & Drager Evita XL) </li></ul>
    120. 123. Summary <ul><li>PEEP can be managed by multiple options, Goal is to prevent repeated alveolar opening and closing, and proper recruitment of dependent lung units </li></ul><ul><li>Alternative Modes can improve specific indices, but lack appropriate randomized clinical trials for universal acceptance </li></ul><ul><li>Optimize settings to improve gas distribution on conventional modes </li></ul>
    121. 124. Thank Y’all for having me!!
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